ACG Clinical Guidelines: Clinical Use of Esophageal Physiologic Testing

Abstract

Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.

Figure 1.

Clinical scheme for the evaluation of esophageal symptoms. Endoscopy is typically performed in the evaluation of persisting esophageal symptoms to look for a structural or mucosal mechanism of symptoms; if abnormal, management proceeds accordingly. Pathways for the evaluation of obstructive, typical, and extraesophageal symptoms suspicious for reflux and atypical symptoms (belching and rumination) differ. A PPI test may be an appropriate starting point for typical esophageal symptoms without alarm features; although this does not provide conclusive evidence of GERD, this is a pragmatic approach because most typical reflux patients do not need further invasive testing. However, objective evidence on esophageal reflux monitoring can predict the management outcome in both typical and extraesophageal reflux symptoms. Manometry helps identify major motor disorders as a mechanism for obstructive symptoms, may rule out confounding motor diagnoses in reflux presentations, and may assist with the diagnosis in atypical presentations. Provocative testing during manometry varies as goals of provocative testing also vary according to the symptom pathway. A timed upright barium swallow is a useful, safe, and inexpensive approach to evaluation of obstructive symptoms when appropriately performed. Barium studies and functional lumen imaging probe (FLIP) provide complementary value to evaluation of obstructive esophageal symptoms. GERD, gastroesophageal reflux disease; HRM, high-resolution manometry; MRS, multiple rapid swallows; PPI, proton pump inhibitor; RDC, rapid drink challenge; SGB, supragastric belching; STM, standardized test meal.